Wgu Accreditation Audit Aft2 Task 4 Essay

2790 Words Sep 27th, 2015 12 Pages
Continuous Accreditation Compliance - Task 4

AFT2 Accreditation Audit

October 31st, 2014

Continuous Accreditation Compliance - Task 4

Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant
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Data compilation and audits have confirmed that this is an ongoing problem that is best resolved by additional training and a considerable amount of follow-up to ensure that implemented changes work and that employees are following policy and procedures. More internal audits should take place in each department on a consistent basis until significant improvement has been made and NCH is found to be compliant in this area.
Lack of Proper Documentation During the PPR it was discovered that 5 departments lacked proper documentation concerning patients and procedures that were department specific. The Joint Commission(n.d.) states that, “The medical record contains the following clinical information: Any observations relevant to care, treatment, and services”( Joint Commission, n.d., RC.02.01.01 - 2). Each department demonstrated different types of a lack of proper documentation. The issue specific to each department are as follows: In 3E nurses did not consistently document in a timely manner because of staffing and morale issues; In Cardiac Cath Lab the Day of procedure was often missing and it was found there was not a regular process in place; In ED it was found that pain assessments and reassessments were missing more often than not; In Endoscopy Day of Procedure Reassessment were often missing and like the Cardiac Cath Lab there was not a regular process in place; and in

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